Long-Term Prognostic Value and Warranty Period for Stress CMR in Patients with Stable Chest Pain: Insights from CE-MARC

Presenting Author(s)

• GB

  Giandomenico Bisaccia, MD, PhD, MSc

  CMR Fellow
  Royal Brompton and Harefield Hospitals
  CHIETI, Abruzzi, Italy

Primary Author(s)

• GB

  Giandomenico Bisaccia, MD, PhD, MSc

  CMR Fellow
  Royal Brompton and Harefield Hospitals
  CHIETI, Abruzzi, Italy

Co-Author(s)

• 

  Peter P. Swoboda, PhD

  Consultant Cardiologist
  Leeds Institute of Cardiovascular and Metabolic Medicine
  Leeds, England, United Kingdom
• JY

  John F. Younger, MB

  Royal Brisbane and Womens Hospital, Queensland, Australia
• NM

  Neil Maredia, MD

  Consultant Cardiologist
  James Cook University Hospital, Middlesbrough, United Kingdom, United Kingdom
• CD

  Catherine J. Dickinson, MD

  Consultant Cardiologist
  Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom, United Kingdom
• 

  Chiara Bucciarelli-Ducci, MD, PhD

  Consultant cardiologist
  Royal Brompton & Harefield NHS Foundation Trust
  London , England, United Kingdom
• 

  Sven Plein, MD, PhD

  Professor of Cardiology
  Leeds Institute of Cardiovascular and Metabolic Medicine
  Leeds, England, United Kingdom
• 

  John Greenwood, MD, PhD, FSCMR

  Director
  Baker Heart and Diabetes Institute
  Melbourne, Victoria, Australia

Background: Few prospective studies have explored the long-term prognostic value and warranty period of stress CMR in patients with stable chest pain. The CE-MARC trial recruited 752 symptomatic patients with suspected angina between 2006 and 2009 and was the first large study to demonstrate the high diagnostic value of stress CMR compared to invasive coronary angiography. The aim of this work was to evaluate the long-term prognostic value of stress CMR in CE-MARC participants.

Methods: Participants in CE-MARC were followed up for major adverse cardiovascular events (MACE), defined as a composite endpoint comprising death from any cause, myocardial infarction, and unscheduled coronary revascularization procedures. Time-to-event analysis for MACE was performed using Kaplan-Meier survival curves with log-rank testing for univariable comparisons and Cox proportional hazards regression for multivariable analysis. The warranty period represents the duration of follow-up during which patients with normal stress CMR maintain an acceptably low cardiovascular risk, operationally defined as the time until the cumulative MACE rate exceeded the 3% safety threshold.

Results: Of the 752 recruited patients, follow-up was completed in 750 (99.7%). At a median of 15.4 years (IQR 15.1-17.0), 205 (27.5%) patients died, and 35 (4.7%) experienced an acute myocardial infarction, while 51 underwent unplanned revascularization (33 with percutaneous coronary intervention and 18 with coronary artery bypass grafting). An abnormal stress CMR was strongly associated with death from any cause (HR 2.03, 95%CI 1.42, 2.92) and subsequent MI (HR 2.58, 95%CI 1.94, 3.44). After adjustment for age, sex, total cholesterol, hypertension, smoking status, diabetes, and family history of coronary artery disease, stress CMR remained a strong MACE predictor (adjusted HR 1.55 95%CI 1.09, 2.20, p = 0.015). For patients with a normal stress CMR, the warranty period for a cumulative MACE rate < 3% was 4.7 years.

Conclusion: In a long-term prospective study of patients with stable chest pain, stress CMR remained a strong, independent predictor of hard cardiovascular events , with a warranty period of almost 5 years for a normal scan.

Cox multivariable regression

Variable	Multivariable Analysis
	HR1	95% CI1	p-value
Age	3.97	2.67, 5.92	< 0.001
Female sex	0.88	0.61, 1.27	0.492
Total cholesterol	0.95	0.81, 1.10	0.475
Hypertension	0.92	0.66, 1.29	0.624
Current smoking	2.66	1.58, 4.50	< 0.001
Diabetes	0.72	0.44, 1.16	0.172
Family history	1.47	0.83, 2.57	0.184
Abnormal stress CMR	1.55	1.09, 2.20	0.015
1 HR = Hazard Ratio, CI = Confidence Interval

Kaplan-Meier curves for MACE